Navigation

Terrifying near-miss leads to critical lessons

On 5 October last year, seven track workers narrowly escaped with their lives when they jumped out of the way of a high speed train a split second before it struck them. Video footage of the incident from the driver’s cab is terrifying. Last month, RAIB published their report and it makes grim reading. Key findings included: the Person in Charge (PiC) did not follow safe work procedures; and the contractors working under him were inhibited from speaking up about their safety concerns for fear of not being invited back to work. So - how can confidential reporting prevent this type of incident?

Speaking up is hard to do

Even where organisations work hard to encourage their staff to report safety concerns, in practice it can be tough – and especially for contractors. In this instance, they signed a document saying they had received a safety briefing when, as the reported to the RAIB investigation later, they felt inadequately briefed.

Why?

The RAIB report concluded that “none of the team involved challenged the unsafe system of work that was in place at the time. Even though some were uncomfortable with it, they feared they might lose the work as contractors if they challenged the PiC.”

Fear of retribution is one of the reasons why reporters come to us. No organisation can eliminate this risk entirely – even where the best possible measures are in place, it can come down to the dynamics of local relationships or the past experience of individuals.

That’s why confidential reporting is so important. It means that workers who do feel inhibited – for whatever reason - have somewhere to go. After all, even if only one worker feels his way, it only takes one incident to lead to tragedy.

The RAIB investigation also found that “the nature of the client/contractor relationship stifled any effective challenge to the unsafe system of work”. At a time when the workforce can be transient we encourage our members to ensure their efforts to raise awareness of CIRAS includes their contractors. It’s easier for them to be left out of the loop. For example, include CIRAS in all site inductions, or hand out info cards to all workers on site.

Good procedures don’t always mean good practice

The RAIB report states “although the PiC was qualified, experienced and was deemed competent by his employer, neither his training nor reassessments had instilled in him an adequate regard for safety and the importance of following the rules and procedures”.

In 2017/8, 15% of our reports related to rules and procedures e.g. either being inadequately communicated or simply not being followed. It’s not enough to have good procedures, and it can be hard to speak up if they’re being flouted. Confidential reports can be a helpful leading indicator that important safety rules are not being followed.

Where a CIRAS report indicates a procedure is not being observed we encourage members to avoid simply quoting the procedure in their response, but to explore beyond that. It’s not uncommon for reports such as this to lead to additional training and re-briefing of staff.

CIRAS exists to help improve workplace safety across the UK transport sector. To achieve that we need our members to ensure their staff know about us and how to use us if they need to. Tragedy was narrowly avoided this time, but on another occasion they may have been less lucky.

Comments

09 Oct 2018

Brett Jennings commented

With changes such as the Safe work Leader / Pic to the safe system of work there is going to be plenty more incidents on project works also. 019 briefing is a recipe for disaster with no one knowing what duties they can and can't be undertaking